CORONAVIRUS (COVID-19)
(updated 09/26/2021 - see bold data)
​Please go to the end of this page for information regarding COVID-19 vaccine and booster and check back as needed for updates

If you are sick, please stay home. 

We require all staff, patients and visitors to wear a mask that covers the mouth and nose. Masks with valves are NOT allowed since they do not prevent the transmission of virus.

We request that for your appointment, you come alone unless assistance is required for translation, you are unable to manage walking by yourself, or have issues with your memory/comprehension.  This precaution is to limit exposure to the visitors, other patients and staff.  If a driver is necessary, we request that they wait outside or in the waiting room.  We hope you understand that we are trying to limit the spread of COVID-19 in any way possible. 
 
Our current guidelines are to continue all the medications prescribed to you by our office including prednisone, biologic therapy, and all DMARD therapy.  However, if you have been exposed to someone who has tested positive for COVID-19 or is undergoing testing for COVID-19, hold biologic therapy/targeted DMARD therapy for 2 weeks (except you may continue Actemra and Kevzara). If you remain symptom free (with no fevers, chills, cough, or shortness or breath), you may resume your biologic therapy. 

​If you have any signs/symptoms of coronavirus such as fever, cough, shortness of breath, loss of smell/taste, we ask that you call your family doctor’s office for guidance regarding testing and treatment for coronavirus.  Continue your Hydroxychloroquine/Chloroquine.  Stop Methotrexate, Leflunomide, Azathioprine, Sulfasalazine.  If you are on steroids (prednisone, methylprednisolone), please call our office for directions.  Steroids should never be stopped abruptly.  Stop targeted DMARD/biologic therapy (Remicade, Humira, Enbrel, Simponi, Cimzia, Orencia, Xeljanz, Olumiant, Rinvoq, Rituxan, Benlysta, Cosentyx, Taltz, Stelara, Tremfya) just as you would hold these medications for any other illness.  However, if you are on Actemra or Kevzara, please call our office for further directions regarding their continued use.
 
If you have a fever, avoid taking lNSAIDs (Ibuprofen, Aleve meloxicam etc).  You may take Tylenol for a fever.  If you already take an NSAID regularly, you may continue to take it as long as you do not have severe respiratory symptoms. 

We understand that with a new disease like COVID-19, recommendations change with time based on new information that is collected.
The current recommendations from the American College of Rheumatology released in 05/2020 report that the "risk of poor outcomes from COVID-19 appear to be related primarily to general risk factors such as age and co-morbidities" (diabetes, heart disease, lung disease, obesity) rather than rheumatic diseases or the use of immunosuppressive therapy.  However, there is a higher risk of hospitalization in rheumatology patients taking prednisone 10mg/day or higher but not with the use of NSAIDs, DMARDs, biologic drugs, JAK inhibitors.
The primary focus is still to avoid getting COVID-19 with practicing social distancing, frequent hand washing.

Based on this information, we are unable to provide a letter specific to your disease or treatment but recommend you discuss it with your employer regarding ways to maintain social distancing per CDC guidelines.

You may return to work or come to the clinic (based on guidelines from the American College of Rheumatology published on 7/13/2020) or resume your medications prescribed by our office (no clear evidence on this yet):

If you have tested positive for COVID-19 and were symptomatic:
- you have been fever free (temperature less than 99 degrees) for at least 72 hours without the use of acetaminophen (Tylenol) or other fever reducing medications (low dose aspirin 81mg/day is OK) 
- have no respiratory symptoms
- AND at least 10 days have passed since the onset of symptoms OR 2 consecutive negative tests by PCR done at least 24 hours apart (you will need the negative tests if you take Tylenol products regularly for pain control and are unable to stop or 72 hours)
- AND at least 20 days have passed since the onset of symptoms IF you are on prednisone 20mg or higher dose/day for more than 2 weeks in the last month OR had a severe/critical illness
- OR at least 3 weeks has passed since the onset of symptoms and you have been asymptomatic for 3 days.

If you have tested positive for COVID-19 and were asymptomatic:
- it is has been at least 10 days since contact with a known positive OR 2 consecutive negative tests by PCR done at least 24 hours apart

If you have had contact with a known positive COVID-19 patient, your test for COVID-19 has to be done at least 5-7 days AFTER the contact. Any test prior to that may be falsely negative. You should self isolate (quarantine) until testing results are known or for 10 days (if unable to get tested). If negative, it is unlikely that you have COVID-19 but if you have symptoms, you must assume you are positive (even if the test is negative) and follow the guidelines for a positive test.

All the currently available vaccines in the US - Pfizer/BioNTech (FDA approved 8/23/2021), Moderna and Johnson and Johnson (received emergency use authorization by the FDA) are not live vaccines.  
The American College of Rheumatology released guidelines (not rules) for the COVID-19 vaccine in patients with rheumatic illness:

EVERYONE SHOULD GET THE VACCINE (DOESN'T MATTER WHICH ONE)
  • No modifications to either immunomodulatory therapy or vaccination timing
    • Hydroxychloroquine (Plaquenil); IVIG; glucocorticoids (steroids), prednisone <20mg/day
    • Sulfasalazine; Leflunomide (Arava); Azathioprine (Imuran); oral Cyclophosphamide (Cytoxan);
    • TNFi (Enbrel, Humira, Remicade, Simponi, Cimzia); IL-6R (Actemra, Kevzara); IL-1 (Anakinra, Kineret); IL-17 (Cosentyx, Taltz); IL-12/23 (Stelara); IL-23 (Tremfya); Belimumab (Benlysta); oral calcineurin inhibitors (cyclosporin, Voclosporin)
  • HOLD Therapy (only if your disease is well controlled - you have not used higher dose prednisone for at least one month; please check with your rheumatologist if you are uncertain about your disease control) 
    • Methotrexate (MTX): Hold MTX one dose after each vaccine dose or on the day of the vaccine if your MTX happens to be on the same day as the vaccine; if you receive a single dose vaccine, hold MTX for 2 doses after the vaccine
    • Cellcept (mycophenolate): Hold for one week after each dose of vaccine
    • JAK Inhibitor (Xeljanz, Rinvoq, Olumiant): Hold JAKi for 1 week after each vaccine dose
    • Abatacept (Orencia): Hold SQ abatacept both one week prior to and one week after the first COVID-19 vaccine dose (only); no interruption around the second vaccine dose
      • IV ABA (Orencia): Time vaccine administration so that the first vaccination will occur four weeks after abatacept infusion (i.e., the entire dosing interval), and postpone the subsequent abatacept infusion by one week (i.e., a 5-week gap in total); no medication adjustment for the second vaccine dose
    • Rituximab (Rituxan): Schedule vaccination so that the vaccine series is initiated approximately 4 weeks prior to next scheduled rituximab cycle; after vaccination, delay Rituxan 2-4 weeks after 2nd vaccine dose, if disease activity allows
    • IV Cyclophosphamide (Cytoxan, CYC): Time CYC infusion one week after each vaccine dose, when feasible

COVID VACCINE BOOSTER
Guidelines released on 8/13/2021 by the CDC/ACIP recommend that any patient on immunocompromising medicines should consider a booster dose of COVID-19 vaccine if the original vaccine was an mRNA vaccine (Pfizer-BioNTech or Moderna) and the 2nd dose of the primary vaccine series was over 28 days prior. 
  • The booster is not recommended for the Johnson and Johnson vaccine (as of now)
  • The booster is not recommended if Hydroxychloroquine is your only disease modifying therapy
  • No antibody testing is recommended after any COVID-19 vaccine or COVID infection to assess response to vaccine or need for booster dose
  • The same mRNA vaccine is recommended for the booster as the original vaccine series if possible
  • Consider the booster dose if were are on any of the following medications with the primary vaccine series – Methotrexate, Leflunomide, Sulfasalazine, Azathioprine, Cellcept/Mycophenolate, Cytoxan, Orencia/Abatacept, JAK inhibitors (Xeljanz, Olumiant, Rinvoq), TNFi (Enbrel, Humira, Remicade, Simponi, Cimzia); IL-6R (Actemra, Kevzara); IL-1 (Anakinra, Kineret); IL-17 (Cosentyx, Taltz); IL-12/23 (Stelara); IL-23 (Tremfya); Belimumab (Benlysta); oral calcineurin inhibitors (cyclosporin, Voclosporin); Ilaris
  • If your rheumatic disease is well controlled, please hold these RA medications for 1-2 weeks after the booster dose (Methotrexate, Leflunomide, Sulfasalazine, Azathioprine, Cellcept/Mycophenolate, Orencia/Abatacept, JAK inhibitors (Xeljanz, Olumiant, Rinvoq), TNFi (Enbrel, Humira, Remicade, Simponi, Cimzia); Belimumab (Benlysta); oral calcineurin inhibitors (cyclosporin, Voclosporin))​
  • If you are on Rituxan infusions, please call the office so we may advise you on the timing of the vaccine
  • If you are on prednisone on a daily basis, please call the office for directions. If you take prednisone as needed, please avoid taking prednisone for at least 2 weeks after the vaccine.
  • If your rheumatic disease is not well controlled, please call the office BEFORE you stop your medications
CDC also strongly recommends:
  • Wearing a mask
  • Staying 6 feet apart from those they don’t live with
  • Avoiding crowds and poorly ventilated indoor spaces until advised otherwise by their healthcare provider
  • Close contacts of immunocompromised people are strongly encouraged to be vaccinated against COVID-19

If you received the Pfizer-BiIoNTech primary series 
  • CDC recommends that the following groups should receive a booster shot of Pfizer-BioNTech’s COVID-19 Vaccine at least 6 months after completing their Pfizer-BioNTech primary series (i.e., the first 2 doses of a COVID-19 vaccine):
    • people aged 65 years and older
    • residents aged 18 years and older in long-term care settings
    • people aged 50–64 years with underlying medical conditions
  • CDC also recommends that the following groups may receive a booster shot of Pfizer-BioNTech’s COVID-19 Vaccine at least 6 months after completing their Pfizer-BioNTech primary series, based on their individual benefits and risks:
    • people aged 18–49 years with underlying medical conditions
    • people aged 18–64 years at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting
 
Underlying medical conditions include:
  • Cancer
  • Chronic kidney disease
  • Chronic lung disease (asthma, COPD, pulmonary HTN, ILD, cystic fibrosis)
  • Dementia
  • Diabetes
  • Down’s syndrome
  • Heart disease (CAD, heart failure, cardiomyopathy)
  • High blood pressure
  • HIV
  • Weakened immune system (related to disease or medications)
  • Liver disease
  • BMI>25
  • Pregnancy
  • Sickle cell disease/thalassemia
  • Smoking (current or former)
  • Transplant (solid organ or stem cell)
  • Stroke
  • Substance abuse (alcohol, opioid, cocaine)
 

If you are exposed to COVID-19 2 weeks after you have been vaccinated, you should get tested 5 days after exposure and maintain all other precautions w.r.t. masking and social distancing until test results are known. If you test positive or have symptoms suggestive of COVID-19, then you should quarantine for 10 days from symptoms onset. 

You may receive the COVID-19 booster dose and flu shot on the same day

Here is a link to more information about vaccines against COVID-19:

https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/covid-19-faqs-medication-treatment-and-vaccines

https://www.nejm.org/covid-vaccine/faq

We ask that you follow the guidelines suggested by CDC and please review the following website for additional up to date information.
www.coronavirus.gov​